Provider Demographics
NPI:1891294195
Name:HALVORSON, AMANDA LYNN (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:HALVORSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LYNN
Other - Last Name:MUNDINGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:3456 N FARWELL BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCK CITY
Mailing Address - State:IL
Mailing Address - Zip Code:61070-9783
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5970 CHURCHVIEW DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-2574
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016873363L00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1891294195Medicaid